J10 Appendix C Accident and Mishap Report AF Form 37.docx
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- Attached to
- ManliftS MX
- Solicitation number
- FA448426R0003
About this file
This file is an appendix containing the Air Force Form 37 mishap report template and instructions for Joint Base McGuire-Dix-Lakehurst personnel. The document is not directly related to the referenced federal contract opportunity for manlift inspection and repair services.
The form serves as a standardized preliminary accident and mishap reporting document for the Air Force, designed to capture comprehensive incident data across multiple categories. The personnel data section collects information about the injured or involved individual, including name, rank, age, duty status, and specific details about the injury sustained. The vehicle and equipment data section documents information about any involved machinery or vehicles, including manufacturer, model, identification numbers, and damage sustained. Critical sections include a synopsis requiring description of events leading to the mishap and corrective actions taken to prevent recurrence, along with certification signatures from the supervisor and unit commander. The form concludes with a wing safety review section. The instructions provided clarify each field's requirements, specifying that reporters should include specific details such as precise injury locations, equipment descriptions, repair hours, and material costs. This template is part of the base's safety management and incident documentation procedures, not a procurement document related to the manlift inspection services solicitation.
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Text version
JOINT BASE MCGUIRE-DIX-LAKEHURST MISHAP REPORT
FOR OFFICIAL USE ONLY WHEN FILLED IN SEE REVERSE FOR INSTRUCTIONS
PERSONAL DATA
1. Mishap Date
2. Mishap Time
3. Name (Last, First’ MI)
4. Rank
| 5. AFSC |
| 6. Age |
| 7. Sex |
8. Unit
9. Duty phone
10. PPE type
11. Duty Status (Check One)
On Duty Off Duty
12. Mishap Location (Check One)
On Base Off |Base
13. Job/Task or Activity
14. Description of Injury
15. Workdays Lost
Hospital___________ Quarters____________
VEHICLE/EQUIPMENT DATA
16. Manufacture
| 17. Make/Model |
| 18. Lic/Reg/Serial/Tail Number |
| 19. year |
| 20. USAF Property |
Yes No
21. Description
22. PPE Used
Yes No
| 23. PPE Type |
| 24. Damage Description |
| 25. Repair Hours |
| 26. Material Cost |
SYNOPSIS
27. DESCRIPTION OF EVENTS THAT RESULTED IN MISHAP (Continue on reverse in necessary)
28. CORRECTIVE ACTION TAKEN TO PREVENT RECURRENCE
Appendix C- Accident ad Mishap Report AF From 37
CERTIFICATION
29. Supervisor’s Name
30. Rank
31. Duty Phone
| 32. Unit Safety Review |
| 33. Unit Commanders Signature |
WING SAFETY USE ONLY
34. Date Received
| 35. Reviewing Person |
| 37 Notes/Memo |
JBMDL FORM 37,
INSTRUCTIONS FOR COMPLETING PRELIMINARY MISHAP REPORT
PERSONNEL DATA
ITEM
| 1. | Date mishap occurred. | |
| 2. | Time mishap occurred. If unknown provide estimated time. | |
| 3. | Self-explanatory. | |
| 4. | Military rank or civilian pay grade. | |
| 5. | Military AFSC or civilian job series number. | |
| 6. | Age of person injured/involved at time of the mishap. | |
| 7. | Indicate M (male) or F (female). | |
| 8. | Unit to which individual was assigned at the time of the mishap. | |
| 9. | Duty phone of the individual being reported. | |
| 10. | Personal protective equipment | |
| 11. | Check the appropriate duty status. | |
| 12. | Check on base or off base and indicate the specific location (Bldg. 1234, CES Carpenter Shop, Highway 38 near | |
| Mt Holly). | ||
| 13. | Indicate job task or activity in which the person was involved at the time of the mishap (operating table saw, playing | basketball, etc.). |
| 14. | Describe specific injury and part of body injured (fractured left leg, lacerated right index finger, etc.). | |
| 15. | Indicate number of days hospitalized or placed on quarters in the appropriate space. |
VEHICLE/EQUIPMENT DATA
| 16. | Indicate manufacturer of vehicle or equipment (Ford, Black & Decker, Boeing, etc.). | |
| 17. | Indicate make or model of vehicle or equipment (Bronco, B-4, C-141, etc.). | |
| 18. | Indicate license number of POV’s reg. number for AF motor vehicles, serial number for equipment, and tail number | of aircraft. |
| 19. | Self-explanatory. | |
| 20. | Self-explanatory. | |
| 21. | Describe vehicle or equipment (4 door sedan, maintenance stand, drill press, etc.). | |
| 22. | Indicate whether personal protective equipment (PPE) was used for the task activity performed. | |
| 23. | Indicate the type of PPE required for the task or activity (seat belts, steel-toed shoes, etc.). | |
| 24. | Describe the damage to the vehicle or the equipment (dent to front left quarter panel, punctured fuel tank, etc.). | |
| 25. | Indicate man-hours required to repair damaged vehicles or equipment. | |
| 26. | Indicate the cost of materials required to repair the damaged vehicle or equipment. | |
| 27. | Describe the events that resulted in the mishap. Explain why this mishap occurred. | |
| 28. | State the corrective action taken by supervisory or higher level within the unit to prevent future similar mishaps. | |
| 29 through 37 self-explanatory. |
Item 27 (continued)
JBMDL 37 (Previous form is obsolete)
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